Dehydration in Newborns and Young Children PDF

Dehydration: +-----------------------------------------------------------------------+ | **Introduction** | +=======================================================================+ | Newborns and young children have a much higher water content t...

Dehydration: +-----------------------------------------------------------------------+ | **Introduction** | +=======================================================================+ | Newborns and young children have a much higher water content than | | adolescents and adults and are more prone to water, sodium (Na​^+^) | | and potassium (K​^+^) loss during illness. | | | |   | | | |   | +-----------------------------------------------------------------------+ | **Goals of Therapy** | +-----------------------------------------------------------------------+ | - Treat shock/impending shock | | | | - Treat dehydration using an appropriate fluid and route | | | | - Treat electrolyte imbalances | | | | - Prevent complications (seizures or edema) | | | | - Provide education to family members to help prevent recurrence | +-----------------------------------------------------------------------+ | **Investigations** | +-----------------------------------------------------------------------+ | - Thorough history with attention to: | | | | - underlying cause(s): vomiting and/or diarrhea or other | | excessive fluid loss | | | | - frequency and amount of loss | | | | - frequency and amount of urinary output | | | | - Physical examination including​ heart rate, respiratory rate, | | blood pressure, temperature, oxygen saturation and capillary | | refill | | | | - Laboratory tests: serum Na​^+^, K​^+^, Cl​^−^, urea, creatinine, | | glucose and bicarbonate (HCO~3~​^-^), blood gases and urinalysis | | as indicated clinically | | | | - The assessment of dehydration in infants and children is | | challenging because children are able to maintain adequate blood | | pressure despite moderate to severe dehydration. | | | |   | | | |  | | | |   | | | | [Severity Of Dehydration:]  | | | | Weight loss infants \1 yr:]  | | | | Mild-3-4%  | | | | Mod-6-8%  | | | | Severe- 10%  | | | |   | +-----------------------------------------------------------------------+ | **Therapeutic Choices** | +-----------------------------------------------------------------------+ | **[Pharmacologic choices:]** | | | |   | | | | **Intravenous Rehydration Therapy** | | | | - Treatment of dehydration involves replacing fluid deficits, then | | maintaining normal hydration. | | | | - Shock occurs when adequate tissue perfusion cannot be maintained | | | | - The systolic blood pressure at which this happens varies with | | age: | | | | - neonates, \ | | | | - The calculation of the fluid deficit for a given degree | | of dehydration can be based on historical or objective | | information, e.g., predehydration and present dehydrated weight. | | When the predehydration weight is known: | | | | - Deficit litres (L) = predehydration weight (kg) -- present weight | | (kg). | | | | - For children ≥1 year, predehydration body weight can be estimated | | by: | | | | - Body weight (kg) = 3 × age (y) + 7. This gives an estimated | | weight at or about the 50​^th^ percentile for age and can be | | used for children up to 10 years of age. | | | | - Maintenance fluid (see [Table | | 3](https://cps.pharmacists.ca/search#c0083n00028), [Table | | 4](https://cps.pharmacists.ca/search#c0083n00030)) is the amount | | of fluid required to maintain normal hydration. Maintenance | | fluids are linked to caloric requirements and take into account | | insensible losses. | | | |  | | | |   | | | | A screenshot of a white sheet Description automatically generated | | | |   | | | | - Dehydration is classified into 3 types depending on serum | | Na​^+^ concentration  | | | |   | | | |  | | | |   | | | | - **Isonatremic dehydration** | | | | - most common form of dehydration, with loss of both K​^+^ and | | Na​^+^ | | | | - K​^+^ can be added to the IV mixture following establishment | | of urinary output. | | | | - K​^+^ administration should not normally exceed 4 mmol/kg/day | | | | - Higher K​^+^ concentrations can be used in life-threatening | | hypokalemia. | | | | - **Hypernatremic dehydration**  | | | | - usually develops slowly and is corrected slowly to prevent | | cerebral edema and seizures. | | | | - Shock is treated aggressively by administering IV NaCl 0.9% | | until urinary output is re-established, then NaCl 0.45% + 5% | | dextrose in water (D5W) is used to correct dehydration states | | and restore Na​^+^ to normal levels. | | | | - The goal of therapy is to reduce serum Na​^+^ by 10--15 | | mmol/L/day and to restore hydration to normal in no less than | | 48 hours. | | | | - If the serum concentration drops rapidly (\10--15 mmol/L/day | | or \1 mmol/L every 2 hours), change the IV solution to NaCl | | 0.9% + D5W. | | | | | | | | - **Hyponatremic dehydration** is classified into 3 subgroups: | | | | 1. Excessive water | | | | 2. Na​^+^ depletion | | | | 3. Factitious lowering of serum Na​^+^ concentration due to | | increased glucose, electrolytes, lipids and proteins | | | | | | | | 1. Children with serum Na​^+^ \>120 mmol/L rarely demonstrate | | any clinical manifestations. | | | | 2. When **serum Na​^+^ drops below 120 mmol/L**, neurologic | | manifestations (e.g., seizures) are common. | | | | 3. Children who are symptomatic require aggressive replacement | | using hypertonic saline (NaCl 3%) to achieve a serum | | Na​^+^ \>125 mmol/L.  | | | | 4. Hyponatremia correction should be carried out carefully and | | monitored closely. | | | | 5. Correction should occur quickly until serum Na​^+^ is \>125 | | mmol/L. The remaining correction above 125 mmol/L should | | occur over 8 hours. | | | | 6. In general, 2--4 mL/kg of NaCl 3% is given at a rate of 1--3 | | mL/kg/hour. Serum sodium will increase by approximately 5 | | mmol/L for every 6 mL/kg of NaCl 3% | | | |   | | | | Serum Na​^+^ deficit can be calculated as follows: | | | | Na​^+^ deficit (mmol) = \[Na​^+^ desired -- Na​^+^ actual (mmol/L)\] | | × body weight (kg) × total body water (L/kg) | | | | After the initial elevation of Na​^+^ to \>125 mmol/L, the remaining | | deficit can be replaced over 24--48 hours in asymptomatic children. | | | |   | | | | - Remember that children who are dehydrated and have ongoing fluid | | losses need to have those fluid losses replaced. | | | | - Those replacements need to be considered in addition to their | | estimated deficit plus maintenance fluids. [The replacement of | | ongoing fluid losses usually occurs in a ratio of 1 mL of | | replacement to each 1 mL of fluid lost.] | | | | - When determining fluid loss and its need for replacement, | | consider excessive loss secondary to high urinary output in a | | patient with diabetes, nasogastric losses, or excessive ongoing | | vomiting and/or diarrhea. Adjust fluid for electrolyte losses as | | well. | | | |   | | | | A screenshot of a computer Description automatically generated | | | |   | | | |   | | | | **Oral Rehydration Therapy** | | | | - Treatment of choice in children with mild to | | moderate dehydration. | | | | - It can be used in all types of dehydration provided that hypo- | | and hypernatremic dehydration are not at the extremes of the | | spectrum. | | | | - In the child who is **mildly to moderately dehydrated**, the | | **rate of replacement is 50 mL/kg over the first 4 hours;** | | | | - for the child who is **moderately to severely dehydrated**, the | | **rate of replacement is 100 mL/kg over the first 4 hours**. | | | | - The rehydration phase may last from 4--12 hours depending upon | | the degree of dehydration as well as the ability of the child to | | tolerate oral rehydration. After the first 4 hours, replace the | | remainder of the deficit over the next 6--8 hours. | | | | -  Ideal solutions for oral replacement therapy contain | | Na​^+^ 45--75 mmol/L, K​^+^ 20 mmol/L and glucose 20--24 g/L; | | 100--150 mL/kg/day is given to the child | | | | - Children who have been started on IV fluid replacement therapy | | should be switched to oral replacement therapy as soon as | | feasible since it is equally effective and is associated with a | | shorter hospital stay | | | | - oral replacement solutions may be delivered via nasogastric tube | | | | - The success of oral rehydration may be improved by the use of an | | antiemetic.  | | | | - **Ondansetron** has the most evidence to support its use in | | this situation | | | | - A **single oral dose** is suggested according to body | | weight as follows: | | | | - 8--14 kg = 2 mg, | | | | - 15--30 kg = 4 mg, | | | | - \>30 kg = 6--8 mg.​ | | | | - The most significant reported **side effect is | | diarrhea**. | | | | - IV doses of 0.1--0.15 mg/kg can be administered if the | | patient is intolerant of the oral preparation. | | | | - Oral rehydration should begin 15--30 minutes following | | administration of ondansetron | | | |   | | | | -  | | | |   | | | | \*\*breastfeed infants: | | | | - It is impossible to determine how much fluid is being consumed | | during breastfeeding, so **breastfeeding should be held** during | | rehydration. | | | | - Once oral rehydration is complete, infants **older than 6 months | | of age can return to breastfeeding** or oral feeding with | | formula. In **infants less than 6 months of age, restart the | | child on breast milk or half-strength formula** | +-----------------------------------------------------------------------+ | **Therapeutic Tips** | +-----------------------------------------------------------------------+ | - Absolute indications for admission to hospital are: | | | | - shock | | | | - hypo-/hypernatremia | | | | - intractable vomiting/diarrhea | | | | - altered sensorium | | | | - Possible indications for admission to hospital are: | | | | - serum HCO~3~ \ | | | | - **Immune control:** In this phase the immune system becomes | | stronger and starts to control the virus.  | | | | - negative hepatitis B e-Antigen (HBeAg) test  | | | | - can still pass the virus to others | | | | - A very small number of people with chronic hepatitis B | | infection can completely clear the virus: if a person has a | | negative result on a HBsAg test, they are considered to have | | a functional cure from hepatitis B. | | | | - **Immune escape:** virus can start replicating again in some | | people after periods of inactivity | | | | - Reactivation can occur on its own, but it is often caused by | | treatments involving immunosuppression | | | | - Most reactivation cases resolve spontaneously, but if the | | reactivation continues and becomes chronic hepatitis B again, | | there is a higher risk of severe liver disease like cirrhosis | | and hepatocellular carcinoma. | +-----------------------------------------------------------------------+ | **Hepatitis B in infants and pre-adolescent children** | +-----------------------------------------------------------------------+ | - passed from a pregnant parent to their child | | | | - results in a chronic infection | | | | - risk of hepatitis B transmission through breastfeeding | | (chestfeeding) is negligible | | | | - But person with hepatitis B has cracked or bleeding nipples | | then breastfeeding should be temporarily stopped until they | | are healed | | | | - horizontal transmission, which can occur in unvaccinated | | pre-adolescent children who have close contact with someone with | | hepatitis B | | | | - pregnant people screened for hepatitis B so that they can be | | offered the care they need if their test result is positive | | | | - If a pregnant person has a high viral load, hepatitis B treatment | | in the third trimester can reduce the risk of transmission to the | | baby. The treatment can continue up to three months after | | delivery to stop the flaring up of hepatitis B, which occurs in | | 30 percent of people after delivery. | | | | - hepatitis B antiviral treatments are considered safe for use in | | pregnancy | | | | - infants born to a pregnant parent who has hepatitis B are given | | one dose of hepatitis B antibodies (hepatitis B immunoglobulin) | | at birth and receive their first dose of hepatitis B vaccine | | within 12 hours of birth | | | | - perinatal transmission occurs in a small percentage of babies | | | | - delay in administering the hepatitis B antibodies and the | | first dose of vaccine, | | | | - hepatitis B transmission may occur while the baby is still in | | the parent's uterus, or | | | | - the baby may not receive the rest of their hepatitis B | | vaccine course in the first months of life | | | | - children receive three doses of hepatitis B vaccine as part of | | their routine infant vaccinations | +-----------------------------------------------------------------------+ | **How is hepatitis B transmitted?** | +-----------------------------------------------------------------------+ | -  passed when virus in the blood, semen, vaginal or other bodily | | fluids of a person who has transmissible hepatitis B (HBsAg+) | | enters the body of another person | | | | - sexual contact or in the context of sharing drug use equipment. | | | | - hepatitis B can be passed through sharing personal care items, | | such as toothbrushes, nail clippers and razors, that may have | | blood containing the virus on them | | | | - spread through the use of unsterilized medical, dental and | | surgical equipment. | | | | - needle-stick injury | | | |   | +-----------------------------------------------------------------------+ | **How can hepatitis B transmission be prevented?** | +-----------------------------------------------------------------------+ | - **Vaccination** | | | | - reduced with correct and consistent use of condoms | | | | - using new drug use equipment every time for preparing, injecting | | or snorting drugs. | | | | - limiting contact with objects (needles, toothbrushes, dental | | floss, razors, bandages, glucometers, nail clippers) that may | | have come into contact with blood and other bodily fluids that | | contain the hepatitis B virus.  | +-----------------------------------------------------------------------+ | **Emergency treatment (post-exposure prophylaxis)** | +-----------------------------------------------------------------------+ | - a shot of hepatitis B immunoglobulin (which contains antibodies) | | and hepatitis B vaccine within 48 hours of exposure. | +-----------------------------------------------------------------------+ | **Who can get hepatitis B?** | +-----------------------------------------------------------------------+ | - Sexual factors (such as having sexual contact with a person who | | has hepatitis B or having a new sexual partner or more than two | | sexual partners in the past year), | | | | - a family history of hepatitis B and | | | | - household contact with someone with hepatitis B, or | | | | - being the recipient of a blood transfusion or medical procedure | | in Canada before 1970 are associated with an increased risk of | | hepatitis B infection. | +-----------------------------------------------------------------------+ | **Populations at higher risk of hepatitis B in Canada** | +-----------------------------------------------------------------------+ | -  Indigenous people, | | | | - people who inject drugs, | | | | - men who have sex with men (MSM), | | | | - people who are street involved or homeless, and | | | | - those who have been incarcerated. | +-----------------------------------------------------------------------+ | **Who should be screened and vaccinated for hepatitis B?** | +-----------------------------------------------------------------------+ | A yellow box with black text Description automatically generated | | | |   | +-----------------------------------------------------------------------+ | **Contact tracing and partner notification** | +-----------------------------------------------------------------------+ | - reportable infection | | | | - PHAC recommends that all contacts of the diagnosed person should | | be screened to assess their status and to provide vaccine | | protection to those who are not immune. | +-----------------------------------------------------------------------+ | **What is the treatment for hepatitis B?** | +-----------------------------------------------------------------------+ | - **Acute hepatitis B does not typically require treatment** | | | | - **Treatment for chronic hepatitis B** | | | | - Treatment is required when the immune system is unable to | | control the virus or there is ongoing liver damage | | | | - These treatments do not offer a complete cure or completely | | eliminate the risk of liver cancer | | | | - **interferon-based treatments** that are taken weekly by | | injection, and | | | | - **antiviral pills (nucleos(t)ide analogues)** that are taken | | daily | +-----------------------------------------------------------------------+ | **What do you need to know about HIV--hepatitis B coinfection?** | +-----------------------------------------------------------------------+ | - share common transmission routes,  | | | | - at risk for hepatitis B infection are also at risk for HIV | | infection | | | | - those with HIV are at increased risk for developing chronic | | hepatitis B if they have not been vaccinated | | | | - some people with HIV who were vaccinated against hepatitis B | | virus in the past can lose their immunity to hepatitis B | | | | - Those with HIV-Hepatitis B progresses faster and causes more | | liver-related health problems, such as cirrhosis, liver cancer | | and liver failure | | | | - coinfection have a higher risk of developing hepatotoxicity | | (severe liver injury) when they start HIV antiretroviral therapy | | | | - infection with hepatitis B does not speed up the progression of | | HIV or affect the response of HIV to antiretroviral therapy. | | | | - The medications used to treat hepatitis are also active against | | HIV.  | | | | -  Putting someone with untreated HIV on hepatitis B therapy can | | create drug resistance to HIV | | | | - If someone with HIV is taking a drug combination that includes | | drugs that are also active against hepatitis B, they may | | experience a temporary worsening or reactivation of their | | hepatitis B infection if they change or stop their HIV treatment | | | | - to prevent HIV transmission, patients will take pre-exposure | | prophylaxis (PrEP) and post-exposure prophylaxis (PEP) | | | | - also active against hepatitis B | | | | - Discontinuation of PrEP or PEP may cause a reactivation of | | hepatitis B infection | +-----------------------------------------------------------------------+ | **What do you need to know about hepatitis B and C coinfection?** | +-----------------------------------------------------------------------+ | - share some common transmission routes | | | | - Anyone who is diagnosed with hepatitis C should also be screened | | for hepatitis B and vice versa | | | | - When people have two active infections of the liver, one virus | | dominates the other. | | | | - In most cases, the hepatitis C virus is the dominant virus | | and the hepatitis B virus is suppressed. | | | | - to cure hepatitis C - need to take direct-acting antivirals. | | | | - when a person is cured of hepatitis C, hepatitis B virus can | | flare up | | | | - hepatitis B treatment may be considered to stop the | | reactivation of hepatitis B | +-----------------------------------------------------------------------+ | **How can people with chronic hepatitis B infection live well?** | +-----------------------------------------------------------------------+ | - ***A healthy and balanced*** diet  | | | | - ***Being active*** is part of staying healthy | | | | - Light to moderate exercise | | | | - 15--30 minutes, three times per week | | | | - stop or reduce their alcohol use. | | | | - ***Prescription or non-prescription drugs or herbal | | supplements*** should only be taken in consultation with a | | healthcare provider | +-----------------------------------------------------------------------+     Hep C: +-----------------------------------------------------------------------+ | **Hepatitis C treatment** | +=======================================================================+ |  | | | | - Cure prevents any further liver injury by the hepatitis C virus | | and prevents progression to end-stage liver disease. | | | | - cured can also improve a person's quality of life | +-----------------------------------------------------------------------+ | **Direct-acting antivirals (DAAs)** | +-----------------------------------------------------------------------+ | -  DAAs block the ability of the hepatitis C virus to replicate | | | | - combinations of two or more types of DAAs | | | | - people will take DAAs with an additional medication called | | ribavirin. | | | | - Ribavirin is an antiviral medication, but it is not a DAA | | | | - Treatment generally means taking one to three pills once a day | | for eight or 12 weeks | | | | - side effects usually mild and diminish or go away completely | | after a few weeks. | | | | - A screenshot of a medical form Description automatically | | generated | | | |   | | | | -  | | | |   | | | | - A screenshot of a white background Description automatically | | generated | | | |   | | | | +--------------------------------+--------------------------------+ | | | Harvoni (ledipasvir + | - age of 18 years with | | | | sofosbuvir) | genotype 1 through 6  | | | | | | | | | | - Approved in children 12 | | | | | years or older with | | | | | genotype 1 | | | | | | | | | | - Harvoni is taken as one | | | | | tablet, once a day, for | | | | | eight, 12 or 24 weeks. | | | | | | | | | | - Treatment generally lasts | | | | | 12 weeks. | | | | | | | | | | - When a person taking | | | | | Harvoni misses a dose and | | | | | it is within 18 hours of | | | | | when it should have been | | | | | taken, it is important to | | | | | take the missed dose | | | | | immediately or as soon as | | | | | possible. | | | | | | | | | | - If it has been more than | | | | | 18 hours since a dose was | | | | | supposed to have been | | | | | taken, that dose should be | | | | | skipped and the next dose | | | | | should be taken at the | | | | | appropriate time | | | | | | | | | | - Contraindicated in | | | | | patients taking | | | | | amiodarone, breastfeed  | | | | | | | | | | - Consult with provider if | | | | | patients have for the most | | | | | appropriate treatment | | | | | plan: | | | | | | | | | | - pregnancy or planning | | | | | a pregnancy while on | | | | | treatment for | | | | | hepatitis C | | | | | | | | | | - liver issues other | | | | | than hepatitis C | | | | | | | | | | - liver transplant | | | | | | | | | | - co-infection with | | | | | hepatitis B | | | | | | | | | | - co-infection with HIV | | | | | | | | | | - rare hereditary | | | | | condition of galactose | | | | | (milk sugar) | | | | | intolerance | | | | | | | | | |   | | | | | | | | | | - Side effects: | | | | | | | | | | - fatigue (extreme | | | | | tiredness) | | | | | | | | | | - Headache | | | | | | | | | | - Drug interactions: | | | | | | | | | | - amiodarone, a | | | | | medication to treat | | | | | irregular heartbeat | | | | | | | | | | - some anti-seizure | | | | | medications, such as | | | | | carbamazepine | | | | | (Tegretol), | | | | | phenobarbital and | | | | | phenytoin (Dilantin) | | | | | | | | | | - some tuberculosis | | | | | medications, such as | | | | | rifampin and | | | | | rifapentine | | | | | | | | | | - the HIV medication | | | | | tipranavir (Aptivus) + | | | | | ritonavir (Norvir) | | | | | | | | | | - the | | | | | cholesterol-lowering | | | | | medication | | | | | rosuvastatin (Crestor) | | | | | | | | | | - any medicinal herbs, | | | | | especially St. John's | | | | | wort (*Hypericum | | | | | perforatum*), which is | | | | | an herb used to treat | | | | | depression, or | | | | | hyperforin or | | | | | hypericin, which are | | | | | active ingredients in | | | | | St. John's wort | | | | | | | | | | - When taking with the | | | | | following medications. | | | | | Could cause potential | | | | | significant DI: | | | | | | | | | | - antacids or buffered | | | | | medications, such as | | | | | Tums, milk of magnesia | | | | | and calcium | | | | | supplements | | | | | | | | | | - medications to treat | | | | | indigestion, heartburn | | | | | or ulcers, such as | | | | | nizatidine (Axid), | | | | | famotidine (Pepcid AC, | | | | | Peptic Guard), | | | | | ranitidine (Zantac), | | | | | esomeprazole (Nexium), | | | | | lansoprazole | | | | | (Prevacid), omeprazole | | | | | (Losec), pantoprazole | | | | | (Pantoloc), | | | | | rabeprazole (Aciphex) | | | | | and cimetidine | | | | | (Tagamet) | | | | | | | | | | - the heart drug digoxin | | | | | (Lanoxin, Toloxin) | | | | | | | | | | -  taken for eight, 12 or 16 | | | | | weeks | | | | | | | | | | - never been treated | | | | | before will take | | | | | Maviret for eight | | | | | weeks | | | | | | | | | | -  previous treatment- | | | | | length of treatment | | | | | depends on the absence | | | | | or presence of severe | | | | | liver injury, the | | | | | genotype of the virus | | | | | and past treatment | | | | | experience. | | | | | | | | | | - adults and children who | | | | | are 12 years or older or | | | | | weigh 45 kg or more | | | | | | | | | | - three tablets once a | | | | | day | | | | | | | | | | - 3 years or older and weigh | | | | | at least 12 kg but less | | | | | than 45 kg.  | | | | | | | | | | - taken as granules in | | | | | sachets once a day | | | | | +================================+================================+ | | | Maviret (glecaprevir + | - for the treatment of | | | | pibrentasvir) | chronic hepatitis C in | | | | | adults and children who | | | | | are 3 years or older, | | | | | weigh 12 kg or more and | | | | | have any genotype of the | | | | | hepatitis C virus. | | | | | | | | | | - also approved in Canada | | | | | for those who have | | | | | previously taken some | | | | | types of direct-acting | | | | | antivirals but were not | | | | | cured of hepatitis C | | | | | | | | | | - those with any | | | | | genotype of the virus | | | | | who have taken | | | | | treatment containing | | | | | (peg)interferon, | | | | | ribavirin and/or a | | | | | direct-acting | | | | | antiviral medication | | | | | called | | | | | sofosbuvir, *without*  | | | | | a | | | | | type of medication | | | | | called an NS3/4A | | | | | protease inhibitor or | | | | | an NS5A inhibitor, and | | | | | who were not cured of | | | | | hepatitis C | | | | | | | | | | - those with genotype 1 | | | | | of the virus who have | | | | | taken direct-acting | | | | | antivirals *with* a | | | | | type of medicine | | | | | called an NS5A | | | | | inhibitor or an NS3/4A | | | | | protease inhibitor | | | | | (but not both), and | | | | | who were not cured of | | | | | hepatitis C | | | | | | | | | | - Consult with provider if | | | | | patients have for the most | | | | | appropriate treatment | | | | | plan: | | | | | | | | | | - severe liver injury | | | | | like Child--Pugh B or | | | | | C cirrhosis | | | | | | | | | | - pregnancy or planning | | | | | a pregnancy while on | | | | | treatment for | | | | | hepatitis C | | | | | | | | | | - liver problems other | | | | | than hepatitis C | | | | | | | | | | - previous liver or | | | | | kidney transplant | | | | | | | | | | - co-infection with | | | | | hepatitis B | | | | | | | | | | - co-infection with HIV | | | | | | | | | | - rare hereditary | | | | | condition of galactose | | | | | (milk sugar) | | | | | intolerance | | | | | | | | | | - diabetes | | | | | | | | | | - Side effects: | | | | | | | | | | - headache | | | | | | | | | | - fatigue (extreme | | | | | tiredness) | | | | | | | | | | - diarrhea | | | | | | | | | | - nausea | | | | | | | | | | - rash or itchy skin | | | | | (pruritus) | | | | | | | | | | - contraindicated (should | | | | | not be used) with Maviret: | | | | | | | | | | - the blood thinner | | | | | dabigatran etexilate | | | | | (Pradaxa) | | | | | | | | | | - the tuberculosis | | | | | medication rifampin | | | | | (Rifadin, Rofact) | | | | | | | | | | - HIV medications that | | | | | contain atazanavir | | | | | (Reyataz) | | | | | | | | | | - oral contraceptives | | | | | (birth control pills) | | | | | that contain ethinyl | | | | | estradiol drugs | | | | | | | | | | - the | | | | | cholesterol-lowering | | | | | medications | | | | | atorvastatin (Lipitor) | | | | | and simvastatin | | | | | (Zocor) | | | | | | | | | | - not recommend taking | | | | | Maviret with the following | | | | | medications: | | | | | | | | | | - some anti-seizure | | | | | medications, such as | | | | | carbamazepine | | | | | (Tegretol), | | | | | phenobarbital and | | | | | phenytoin (Dilantin) | | | | | | | | | | - any medicinal herbs, | | | | | especially St. John's | | | | | wort (*Hypericum | | | | | perforatum*), which is | | | | | an herb used to treat | | | | | depression, or | | | | | hyperforin or | | | | | hypericin, which are | | | | | active ingredients in | | | | | St. John's wort | | | | | | | | | | - HIV medications that | | | | | contain efavirenz | | | | | (Sustiva, and in | | | | | Atripla) or | | | | | lopinavir/ritonavir | | | | | (Kaletra) or ritonavir | | | | | (Norvir) + darunavir | | | | | (Prezista) | | | | | | | | | | - the | | | | | cholesterol-lowering | | | | | medication lovastatin | | | | | | | | | | - the immune-suppressant | | | | | medication | | | | | cyclosporine above 100 | | | | | mg per day | | | | | | | | | |   | | | | | | | | | | - When taking with the | | | | | following medications. | | | | | Could cause potential | | | | | significant DI: | | | | | | | | | | - the heart drug digoxin | | | | | (Lanoxin, Toloxin) | | | | | | | | | | - the | | | | | cholesterol-lowering | | | | | medications | | | | | pravastatin | | | | | (Pravachol) and | | | | | rosuvastatin (Crestor) | | | | | | | | | | - the immune-suppressant | | | | | medication tacrolimus | | | | | (Prograf, Advagraf, | | | | | Protopic) | | | | | | | | | | - HIV medications that | | | | | contain rilpivirine | | | | | (Edurant, and in | | | | | Juluca, Complera and | | | | | Odefsey) | | | | | | | | | | - vitamin K antagonist | | | | | medications that | | | | | reduce clotting, such | | | | | as warfarin (Coumadin) | | | | | | | | | |   | | | +--------------------------------+--------------------------------+ | | | Vosevi (sofosbuvir + | - for people over the age of | | | | velpatasvir + voxilaprevir) | 18 years with chronic | | | | | hepatitis C who either do | | | | | not have cirrhosis or have | | | | | compensated cirrhosis in | | | | | the following situations: | | | | | | | | | | - people with any | | | | | genotype of hepatitis | | | | | C virus who have taken | | | | | direct-acting | | | | | antivirals *with* an | | | | | NS5A inhibitor (such | | | | | as daclatasvir, | | | | | ledipasvir, elbasvir, | | | | | ombitasvir, | | | | | velpatasvir and | | | | | pibrentasvir) and who | | | | | were not cured | | | | | | | | | | - people with genotype | | | | | 1, 2, 3 or 4 of the | | | | | hepatitis C virus who | | | | | have taken a | | | | | direct-acting | | | | | antiviral *containing* | | | | |  sofosbuvir | | | | | but *without* an NS5A | | | | | inhibitor and were not | | | | | cured | | | | | | | | | | - taken as one tablet, once | | | | | a day, for 12 weeks. | | | | | | | | | | - fixed-dose combination | | | | | tablet containing 400 | | | | | mg of sofosbuvir, 100 | | | | | mg of velpatasvir and | | | | | 100 mg of voxilaprevir | | | | | | | | | | - Vosevi not be used by | | | | | people who take amiodarone | | | | | | | | | | - Consult with provider if | | | | | patients have for the most | | | | | appropriate treatment | | | | | plan: | | | | | | | | | | - severe liver injury | | | | | like Child--Pugh B or | | | | | C cirrhosis | | | | | | | | | | - pregnancy or planning | | | | | a pregnancy while on | | | | | hepatitis C treatment | | | | | | | | | | - liver problems other | | | | | than hepatitis C | | | | | | | | | | - awaiting a liver | | | | | transplant or a liver | | | | | transplant recipient | | | | | | | | | | - severe kidney injury | | | | | or on dialysis | | | | | | | | | | - co-infection with | | | | | hepatitis B | | | | | | | | | | - co-infection with HIV | | | | | | | | | | - rare hereditary | | | | | condition of galactose | | | | | (milk sugar) | | | | | intolerance | | | | | | | | | | - Side effects: | | | | | | | | | | - headache | | | | | | | | | | - fatigue (extreme | | | | | tiredness) | | | | | | | | | | - lack of energy and | | | | | strength | | | | | | | | | | - diarrhea | | | | | | | | | | - nausea | | | | | | | | | | - sleeping problems | | | | | | | | | | - contraindicated (should | | | | | not be used) with Vosevi: | | | | | | | | | | - the blood thinner | | | | | dabigatran etexilate | | | | | (Pradaxa) | | | | | | | | | | - the anti-seizure | | | | | medications | | | | | phenobarbital and | | | | | phenytoin (Dilantin) | | | | | | | | | | - the tuberculosis | | | | | medication rifampin | | | | | (Rifadin, Rofact) | | | | | | | | | | - any medicinal herbs, | | | | | especially St. John's | | | | | wort (*Hypericum | | | | | perforatum*), which is | | | | | an herb used to treat | | | | | depression, or | | | | | hyperforin or | | | | | hypericin, which are | | | | | active ingredients in | | | | | St. John's wort | | | | | | | | | | - the | | | | | cholesterol-lowering | | | | | medication | | | | | rosuvastatin (Crestor) | | | | | | | | | | - not recommend taking | | | | | Vosevi with the following | | | | | medications: | | | | | | | | | | - amiodarone, a | | | | | medication to treat | | | | | irregular heartbeat | | | | | | | | | | - some anti-seizure | | | | | medications, such as | | | | | carbamazepine | | | | | (Tegretol) and | | | | | oxcarbazepine | | | | | (Trileptal) | | | | | | | | | | - the tuberculosis | | | | | medications rifabutin | | | | | (Mycobutin) and | | | | | rifapentine | | | | | | | | | | - HIV medications that | | | | | contain efavirenz | | | | | (Sustiva, and in | | | | | Atripla), atazanavir | | | | | (Reyataz) and | | | | | lopinavir (in Kaletra) | | | | | | | | | | - the immune-suppressant | | | | | medication | | | | | cyclosporine (Neoral, | | | | | Sandimmune IV) | | | | | | | | | |   | | | | | | | | | | - When taking with the | | | | | following medications. | | | | | Could cause potential | | | | | significant DI: | | | | | | | | | | - antacids or buffered | | | | | medications, such as | | | | | Tums or milk of | | | | | magnesia and calcium | | | | | and magnesium | | | | | supplements | | | | | | | | | | - medications to treat | | | | | indigestion, heartburn | | | | | or ulcers, such as | | | | | nizatidine (Axid), | | | | | famotidine (Pepcid AC, | | | | | Peptic Guard), | | | | | ranitidine (Zantac), | | | | | esomeprazole (Nexium), | | | | | lansoprazole | | | | | (Prevacid), omeprazole | | | | | (Losec), pantoprazole | | | | | (Pantoloc), | | | | | rabeprazole (Aciphex) | | | | | and cimetidine | | | | | (Tagamet) | | | | | | | | | | - the heart drug digoxin | | | | | (Lanoxin, Toloxin) | | | | | | | | | | - HIV regimens that | | | | | contain tenofovir DF | | | | | (Viread, and in | | | | | Truvada, Atripla, | | | | | Complera, Stribild, | | | | | Delstrigo) | | | | | | | | | | - the | | | | | cholesterol-lowering | | | | | medications | | | | | atorvastatin | | | | | (Lipitor), | | | | | fluvastatin, | | | | | lovastatin, | | | | | simvastatin (Zocor) | | | | | and pravastatin | | | | | | | | | | - oral contraceptives | | | | | (birth control pills) | | | | | that contain ethinyl | | | | | estradiol drugs | | | | | | | | | |   | | | +--------------------------------+--------------------------------+ | | | Epclusa (velpatasvir + | - chronic hepatitis C in | | | | sofosbuvir) | adults and children who | | | | | are 12 years or older and | | | | | have any genotype of the | | | | | hepatitis C virus | | | | | | | | | | - It is taken once a day, | | | | | with or without food, for | | | | | 12 weeks. | | | | | | | | | | - Epclusa has few side | | | | | effects | | | | | | | | | | - taken as one tablet, once | | | | | a day, for 12 weeks | | | | | (fixed-combination tablet | | | | | containing 400 mg of | | | | | sofosbuvir and 100 mg of | | | | | velpatasvir) | | | | | | | | | | - Patients with | | | | | decompensated cirrhosis, | | | | | may need to take Epclusa | | | | | with ribavirin | | | | | | | | | | - not be used by people who | | | | | take amiodarone | | | | | | | | | | - Undetermined safety and | | | | | efficacy in people with | | | | | | | | | | - kidney injury | | | | | | | | | | - moderate or severe | | | | | liver injury, such as | | | | | Child--Pugh B or C | | | | | cirrhosis | | | | | | | | | | - Consult with provider if | | | | | patients have for the most | | | | | appropriate treatment | | | | | plan: | | | | | | | | | | - liver problems other | | | | | than hepatitis C | | | | | | | | | | - previous treatment | | | | | with an NS5A inhibitor | | | | | (such as velpatasvir, | | | | | elbasvir, ledipasvir, | | | | | daclatasvir, | | | | | ombitasvir and | | | | | pibrentasvir) | | | | | | | | | | - severe liver injury, | | | | | such as Child--Pugh C | | | | | cirrhosis | | | | | | | | | | - both moderate liver | | | | | injury (Child--Pugh B | | | | | cirrhosis) and severe | | | | | kidney injury or on | | | | | dialysis | | | | | | | | | | - liver transplant | | | | | | | | | | - pregnancy or planning | | | | | to have a baby while | | | | | on treatment for | | | | | hepatitis C | | | | | | | | | | - co-infection with | | | | | hepatitis B | | | | | | | | | | - co-infection with HIV | | | | | | | | | | - Side effects: | | | | | | | | | | - fatigue (extreme | | | | | tiredness) | | | | | | | | | | - headache | | | | | | | | | |   | | | | | | | | | | - Drug interactions: | | | | | | | | | | - amiodarone, a | | | | | medication to treat | | | | | irregular heartbeat | | | | | | | | | | - some anti-seizure | | | | | medications, such as | | | | | carbamazepine | | | | | (Tegretol), | | | | | phenobarbital, | | | | | oxcarbazepine | | | | | (Trileptal) and | | | | | phenytoin (Dilantin) | | | | | | | | | | - some tuberculosis | | | | | medications, called | | | | | rifamycins, such as | | | | | rifampin (Rifadin, | | | | | Rofact), rifabutin | | | | | (Mycobutin) and | | | | | rifapentine | | | | | | | | | | - HIV medications that | | | | | contain efavirenz | | | | | (Sustiva, and in | | | | | Atripla) | | | | | | | | | | - the HIV medication | | | | | tipranavir (Aptivus) + | | | | | ritonavir (Norvir) | | | | | | | | | | - any medicinal herbs, | | | | | especially St. John's | | | | | wort (*Hypericum | | | | | perforatum*), which is | | | | | an herb used to treat | | | | | depression, or | | | | | hyperforin or | | | | | hypericin, which are | | | | | active ingredients in | | | | | St. John's wort | | | | | | | | | | - When taking with the | | | | | following medications. | | | | | Could cause potential | | | | | significant DI: | | | | | | | | | | - antacids or buffered | | | | | medications, such as | | | | | Tums, milk of magnesia | | | | | and calcium | | | | | supplements | | | | | | | | | | - medications to treat | | | | | indigestion, heartburn | | | | | or ulcers, such as | | | | | nizatidine (Axid), | | | | | famotidine (Pepcid AC, | | | | | Peptic Guard), | | | | | ranitidine (Zantac), | | | | | esomeprazole (Nexium), | | | | | lansoprazole | | | | | (Prevacid), omeprazole | | | | | (Losec), pantoprazole | | | | | (Pantoloc), | | | | | rabeprazole (Aciphex) | | | | | and cimetidine | | | | | (Tagamet) | | | | | | | | | | - the heart drug digoxin | | | | | (Lanoxin, Toloxin) | | | | | | | | | | - HIV treatments that | | | | | contain tenofovir DF | | | | | (Viread, and in | | | | | Truvada, Atripla, | | | | | Complera, Stribild, | | | | | Delstrigo) | | | | | | | | | | - cholesterol-lowering | | | | | medications, such as | | | | | rosuvastatin (Crestor) | | | | | and atorvastatin | | | | | (Lipitor) | | | | | | | | |